Summary The HS 125-600A, operated by Scott Aviation, registration number N21SA, serial number 256006, with two crew members and four passengers on board, took off from Montral, Quebec, at 1756 eastern standard time, for a night instrument flight rules flight to Bromont, Quebec. Upon approaching Bromont, the co-pilot activated the lighting system and contacted the approach UNICOM (private advisory service). The flight crew was advised that the runway edge lights were out of order. However, the approach lights and the visual approach slope indicator did turn on. The flight crew executed the approach, and the aircraft touched down at 1825 eastern standard time, 300feet to the left of Runway05L and 1800feet beyond the threshold. It continued on its course for a distance of approximately 1800feet before coming to a stop in a ditch. The crew tried to stop the engines, but the left engine did not stop. The co-pilot entered the cabin to direct the evacuation. One of the passengers tried to open the emergency exit door, but was unsuccessful. All of the aircraft's occupants exited through the main entrance door. Both pilots and one passenger sustained serious injuries, and the three remaining passengers received minor injuries. The aircraft suffered major damage. Ce rapport est galement disponible en franais. Other Factual Information The flight crew was certified and qualified for the flight in accordance with existing regulations. The pilot-in-command had been working for the company since July2004. He had accumulated a total of 5000flight hours, including 550hours on the HS125 as captain and 200hours as co-pilot. At the time of the accident, he was sitting in the left seat and was acting as pilot flying(PF). The co-pilot had been working for the company since October 2004. He had flown approximately 1700flight hours, including 100hours as co-pilot on the HS125. At the time of the accident, he was sitting in the right seat and was acting as pilot not flying(PNF). The aircraft, a HS125-600A, was operated by Scott Aviation, a business aircraft management company that operates 13aircraft. The company's head office is at the DuPage Airport in Illinois, United States. The company holds operating certificate SVTA0235 issued by the Federal Aviation Administration (FAA). The flight was carried out in accordance with Part135 of the Federal Aviation Regulations (FARs). The company also holds a Canadian foreign air operator certificate, numberF-7262, issued by Transport Canada under PartVII, Subpart1, of the Canadian Aviation Regulations (CARs). The general conditions of the Canadian foreign air operator certificate state that the company must conduct its aviation operations in accordance with International Civil Aviation Organization (ICAO) standards and CAR applicable provisions. On the day of the accident, the flight crew reported for work at the DuPage Airport at approximately 1000eastern standard time.1 The aircraft flew to the Middle Georgia Regional Airport and to the Cobb County Airport-McCollum Field in Georgia, United States, before heading to Montral, where it landed at1542. These flights were completed without incident. Before departure from Montral, the captain filed an instrument flight plan with the Qubec, Quebec, flight information centre (FIC). The FIC specialist asked the pilot whether he needed the notices to airmen (NOTAMs), and the pilot indicated that he did not need them. According to the company's standard operating procedures (SOP) manual, the captain is responsible to obtain the NOTAMs before departure. The co-pilot was not informed of the NOTAMs before departure. This was the first time the crew had ever flown to Bromont. According to the flight plan, the planned flight time was 15minutes, and the fuel on board was sufficient for 1.5hours of flight. The aircraft took off from Montral at1756. This was a night flight. No weather observations are taken at the Bromont Airport. The 2300UTC aviation routine weather report (METAR) from the Saint-Hubert Airport, Quebec, located 30 miles from Bromont, was as follows: winds 110degrees True at 5knots, visibility 1 mile in light snow flurries and cloud cover at 2000feet. The investigation showed that similar conditions were prevailing at Bromont at the time of the accident. According to paragraph135.213(b) of the FARs, when a flight is conducted under instrument flight rules, the weather observations produced and given to the pilots must be taken at the airport where the aircraft is heading, unless otherwise authorized by an operating specification issued by the FAAor by a designated person. However, there is no indication that the company had such a specification. The flight crew performed the front course localizer (LOC) approach on Runway05L. Runway05L is a paved runway, 5000feet long and 100feet wide. It is equipped with Jtype aircraft radio control of aerodrome lighting (ARCAL), consisting of approach lights, low intensity runway edge lights and a precision approach path indicator (PAPI). The PAPI is located at the left side of the runway, in accordance with Canadian civil aviation standards. The lighting comes on for approximately 15minutes when the pilot presses the microphone button five times within five seconds. Approximately nine minutes before the landing, the co-pilot activated the ARCAL and contacted the approach UNICOM (AU) at Bromont. The Bromont Airport dispatcher informed the crew that only the PAPI was operational. A NOTAM had been issued on 17February2005, indicating that the runway edge lights would be out of order until 2200UTC, 22February2005. The PAPI and the approach lights lit up when the PNF activated the ARCAL, because their switches had been left on. There is no indication in the CARs or in the airport operating manual that the lights should have been turned off while the runway edge lights were out of order. At approximately 1000feet asl and five miles from the threshold, the flight crew had the approach lights and the PAPI in sight. It was not evident whether the PAPI was positioned on the right or the left side of the runway. The airport chart published by Jeppesen indicated PAPI L (see AppendixA), and interpretation meant that the PAPI was on the left. In response to a query from the crew, the Bromont dispatcher indicated that the PAPI was on the right side of the runway. From his location facing the aircraft, the PAPI was to the dispatcher's right. The approach chart, also published by Jeppesen, showed the position of the PAPI by means of a pictograph, showing a drawing of the runway threshold and the approach lights with the word PAPI on the left side of the drawing (see AppendixB). Although that chart was referred to during the approach, there is no indication that the crew noticed the pictograph. The approach was continued visually, keeping to the left of the PAPI. At approximately two miles from the runway threshold, the co-pilot noticed that the approach lights were at his right. He reported his observation to the captain, who paid little attention to it. The co-pilot concluded that these were the approach lights for Runway05R, although Runway05R was not equipped with runway lights. Less than two seconds before the crash, the co-pilot asked the captain whether he had the runway in sight. The captain did not reply and continued the descent until the aircraft touched down 300feet to the left of Runway05L, 1800feet beyond the threshold. When the captain realized that he was not on the runway, he applied full power to execute a missed approach; however, the aircraft hit a ditch approximately four feet deep that was perpendicular to the flight path. The nose wheel and right landing gear collapsed. The aircraft came to a stop facing back the way it had come, after travelling a distance of 1800feet during which it made a full turn followed by a 180-degreeturn. Once the aircraft had come to a stop, the flight crew attempted to shut down the engines (TFE731-3-1H) by closing the two HPcock levers and the two LPcock levers. However, the left engine did not stop. The investigation showed that the left LPcock lever was blocked at the halfway point. This LPcock is located underneath the fuselage, in a spot that suffered some damage that might have restricted the movement of the bellcrank that activates the LP cock. Since the supply of fuel to the engines can be cut off by means of the HPcock levers under normal operating conditions, it is possible that the mechanical links connecting the left HPcock lever also suffered damage, which prevented the fuel supply from being cut off. The engine finally stopped on its own, 20minutes after the accident. The investigation did not reveal any irregularity in the aircraft that could have contributed to the accident. The co-pilot went into the cabin to direct the evacuation. The passengers had difficulty hearing his evacuation orders because of the noise of the left engine, which was still running. The HS125 is equipped with a main door located at the left front that can be used in case of evacuation, as well as the emergency exit located above the right wing. The emergency exit can be opened from the inside by pulling on a handle to unlock it, or from the outside by pushing a push-button. One of the passengers tried unsuccessfully to open the emergency door. As a result of the fuselage being bent out of shape, the door was jammed in its frame. After the accident, the investigators noted that, despite diligent efforts, it was impossible to push the outside push-button without using a cylindrical object. It was impossible to determine why the push-button was not working properly. A cabinet that served as an armrest for the side seat was partially blocking the emergency exit (see Photo1). The armrest/cabinet is connected to the seat by means of a rail along which it slides when it is necessary to remove it. According to Supplementary Type Certificate (STC) SA4147SW, a notice indicating that the armrest must be removed before each take off and landing must be displayed when the armrest is in position. At the time of the accident, the armrest/cabinet was in position, and the notice stated that the cabinet should be pulled forward in order for the emergency exit to be used. All the occupants left the aircraft through the main door, which proved difficult to open because the fuselage was bent out of shape. The door and its built-in stairway open downwards and could not be fully lowered because of the collapsed front landing gear. One of the passengers tripped over the doorway during the evacuation. Once they were outside the aircraft, the two pilots noticed that the passenger who was seated at the extreme rear of the aircraft had not exited the aircraft. He was unable to move due to his injuries. The crew helped him. Due to the horizontal position of the stairway, one of the passenger's feet got stuck twice while he was being evacuated. The company's General Operations Manual states that, among the duties to be performed during an evacuation, the crew must ensure that all the occupants have left the aircraft before leaving it themselves. According to Section135.117 of the FARs, the pilot-in-command must ensure, before each take off, that the passengers have been given an oral briefing, which must include the following information, among others: how to use the seatbelts; the location of the main doors and emergency exits, and how to use them; the location of survival equipment; how to use the oxygen, under normal conditions and in an emergency; and the location of fire extinguishers and how to use them. The same section states that a printed card must supplement the safety briefing. The ICAO standard concerning the safety briefing is comparable. The passengers did not receive any safety briefing before the departure from Montral or before the previous take-offs made earlier that day. The passengers had not read the printed card. All the passengers were wearing their lap safety belts. However, the two passengers seated on the side seat were not wearing the shoulder straps, which were found behind the back of the seat. Their method of use is so unusual that no one was able to figure it out. Moreover, instructions for their use were not provided in the information leaflet that was found on board. The Bromont municipal police was notified of the accident at 1826, one minute after the crash. The first responders - the police and the fire department - arrived at the scene approximately four minutes later. At 1843, the first of five ambulances arrived at the scene. All the occupants were taken to hospital. After the accident, the Bromont Airport navigation aids were subjected to an in-flight test, which showed that they met operating requirements and that the broadcast parameters were within technical tolerances. No operating irregularity of the navigation aids was reported on the day of the accident. The Bromont Airport is operated by the Rgie aroportuaire rgionale des Cantons de l'Est (Eastern Townships Regional Airport Board), which holds operating certificate 5151-1Q-401. The airport has one paved runway, 05L-23R, which is 5000feet long, and one grass strip, 05R23L, which is 3200feet long and 320feet wide. The grass strip is not equipped with runway lights and is closed in the winter. The airport is at an elevation of 374feetasl. The airport is staffed by one chief dispatcher, five dispatchers and one maintenance officer. The dispatchers look after radio communications, the parking of aircraft, runway safety, refuelling and the issuance of NOTAMs. The dispatcher on duty at the time of the accident held a restricted radio operator's certificate. The communications between the flight crew and the dispatcher were conducted via the AU. With respect to this occurrence, a NOTAM had been issued as required by regulations. Despite the absence of operating runway edge lights, the airport was not considered closed for nighttime use. The CARs do not require an airport operator to evaluate the impact of a reduced level of service provided at the airport and give no guidelines on how to evaluate such an impact. According to the airport operations manual, snow-clearing operations begin when three centimetres of snow have accumulated. A runway surface condition report (RSCR) issued at 0844 that day (that is, nearly eight hours before the accident) indicated that 80percent of the surface was covered with hard snow, and 20percent was bare and dry. The RSCR did not specify the thickness of the snow cover. During the approach, the flight crew was notified that there was a little snow on the entire surface. However, no details on the thickness of the snow and no braking action report were provided to the flight crew. The Bromont Airport does not have any equipment for measuring the braking action and is not required to. The exact quantity of snow on the runway at the time of the accident could not be determined. However, when the investigators arrived at the scene a few hours after the accident, the runway was covered with between one and three centimetres of snow. The weight of the aircraft at landing, as calculated by the crew, was 18200pounds. To determine the landing distance, the crew used a chart included in the normal checklist and determined it to be 4080feet, by rounding the weight up to 19000pounds and the pressure altitude to 1000feet. This distance is the product of the unfactored landing distance on a dry runway, multipliedby1.67. The landing performance diagrams from the flight manual mention three types of runway conditions for determining the unfactored landing distance - dry runway, wet runway and icy runway with a friction coefficient of0.05. There is no diagram referring to a snow covered runway. Based on the diagram corresponding to the aircraft's configuration at the time of landing, it was determined that the unfactored landing distance was 2520feet on a dry runway, 3230feet on a wet runway, and 9300feet on a slippery runway with a friction coefficient of0.05. These distances are based on a weight of 18200pounds and a pressure altitude of 454feet. There is no indication that the flight crew looked at the diagram during the flight planning. According to SOPs, the captain has the final authority and the responsibility to undertake or to cancel a flight. SOPs also indicate that, as soon as a crew member notices that another crew member is taking dangerous actions, or that his actions are contrary to company procedures or to regulations, he must notify the other crew member. When the co-pilot indicated that the approach lights were on the right, the captain did not question the validity of the information and continued with the approach. According to ICAO international standards and recommended practices, a pilot in-command must comply with the laws, regulations and procedures of the country in which the aircraft is flying. Subsection602.40(1) of the CARs states that it is prohibited to take off or land at an aerodrome at night unless the aerodrome has lights in accordance with the requirements stated in PartIII of the CARs. According to subsections301.07(1) and (2), the aerodrome operator shall indicate each side of the runway along its length with a line of fixed white lights that is visible in all directions from an aircraft in flight at a distance of not less than two nautical miles, or else he must use white retro-reflective markers that are capable of reflecting aircraft lights and that are visible at a distance of not less than two nautical miles from an aircraft in flight that is aligned with the centreline of the runway. Neither of these requirements was met when the accident occurred. Landing was prohibited. The FARs runway light requirements for night landings are similar to those of the CARs. They indicate that the boundaries of the surface used for night take-offs or landings must be clearly indicated with side marker lamps or runway lights.